Off-label prescribing of psychotropic drugs to adults on the autism spectrum could be exposing individuals to harm.

Adults on the autism spectrum are being prescribed mental health drugs in instances where there is limited supporting evidence to do so.

This was one of the findings of a UNSW-led study that looked at the use of psychotropic medication – or medication for mental health problems – by adults on the autism spectrum.

The research, which used data collected by The Cooperative Research Centre for Living with Autism (Autism CRC)’s Australian Longitudinal Study of Adults with Autism (ALSAA), found that 14 per cent of mental health medications were being taken by adults on the autism spectrum without a relevant diagnosis.

First author on the study, Dr Rachael Cvejic from UNSW Medicine’s School of Psychiatry, said that in these cases it is “likely that mental health medications were being used to manage behaviour”.

“This is concerning, because there is little evidence to support the use of mental health medications to manage behavioural features of autism spectrum disorders, and this practice exposes people to potential harms,” Dr Cvejic said.

Mental illness

The research, which surveyed 188 adults on the autism spectrum and a control group of 115 people without autism, compared rates of mental illness diagnoses and rates of psychotropic drug prescription in both groups.

While higher rates of mental health issues were reported among adults on the autism spectrum, the higher rates of mental health medication used in this group was not completely explained by the presence of mental health or other neurological diagnoses.

According to the study, published online today in BJPsych Open, the most common types of medications taken without a relevant diagnosis were antipsychotics, antiepileptics, and propranolol (a beta-blocker).

Dr Cvejic said these medications are often used ‘off-label’ to manage behaviours such as aggression, but the reasons behind such prescription could be varied.

“There is no one cause of this phenomenon,” Dr Cvejic said.

“Clinicians may be having difficulties with making an accurate psychiatric diagnosis in adults on the autism spectrum, or there could be potential difficulties with communication.

“Other reasons could be that there is difficulty accessing appropriate non-pharmacological therapies to support behavioural issues, or inadequate education about potential non-pharmacological therapies.”

Training

Dr Cvejic and her fellow authors believe the findings highlight the need for accessible and specific training for clinicians to support responsible prescribing to people on the autism spectrum.

“It is very important that people on the autism spectrum weigh up the potential benefits and risks of a medication with their clinician and establish whether non-pharmacological therapies may be a potential option,” Dr Cvejic said.

For this to happen, clinicians would need to have access to autism spectrum-specific education and training in assessment and management of mental health disorders.

The research paper identifies a number of priorities for training including improved communication strategies, a greater understanding of neurodiversity, the ability to identify physical and mental health comorbidities (additional diseases or conditions) and better knowledge of non-pharmacological therapies where necessary.

Julianne Higgins is on the autism spectrum and acts as an advisor to ALSAA researchers. She said if clinicians had a better understanding of neurodiversity, medication may be used more sparingly.

“I feel that the existential autistic experience of living would be better understood if clinicians had an appreciation of autism within the context of neurodiversity,” Ms Higgins said.

“A familiarity with this perspective may obviate the recourse to medicate as often, particularly in regard to treating co-existing conditions and those arising from autistic difficulties in communication.”

She added that many concerns of people on the autism spectrum would not go unrecognised if “medical training addressed autism in adulthood as well as in children, with attention given to gender and the corresponding manifestations of different autistic traits”.

Action needed

Dr Cvejic said there has been a push to embed such training in programs for all health practitioners in the UK, but flagged the lack of action in Australia as a concern.

“We currently have no way to ensure that all future health practitioners are equipped to meet the needs of people on the autism spectrum,” she said.

“Embedding autism spectrum-specific content in the medical curriculum would help to ensure future doctors are equipped to meet the needs of this group,” Dr Cvejic said.

“Enhancements to training would likely have a positive impact on doctors’ confidence and attitudes when working with people on the autism spectrum as well.”

Autism CRC Chief Research Officer Andrew Whitehouse said while health care providers were very diligent in working with people on the autism spectrum, he welcomed moves to give clinicians improved tools and training to better identify, diagnose and treat mental health issues that people on the autism spectrum might present with.

"This very important study highlights the urgent need for more educational programs for health professionals in the area of autism and mental health. These will be critical to offering optimal healthcare and promoting the wellbeing of the significant number of Australians on the autism spectrum," Professor Whitehouse said.

The ALSAA is now in its second wave of data collection and Dr Cvejic and her fellow researchers will use this information to see how mental health and medication use might change over time.